# 一位個案身上有多處處於不同癒合階段的瘀傷。其伴侶代為回答所有問題。護理師應首先做什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394098&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一位個案身上有多處處於不同癒合階段的瘀傷。其伴侶代為回答所有問題。護理師應首先做什麼？

## 選項

1. 詢問伴侶個案在家中是否安全。
2. 設法與個案私下交談並評估安全。 **✔ 正確答案**
3. 告訴個案立即離開這段關係。
4. 除非個案尋求協助，否則忽略這些發現。

**正確答案: 2**

## 解析

疑似親密伴侶暴力需要進行私密、創傷知情的安全評估。在伴侶面前詢問可能增加危險，並可能妨礙坦誠揭露。護理師應評估立即風險，並遵循機構的通報與安全程序。

## 深入解析

臨床判斷
當可能存在控制或恐嚇時，安全篩檢必須私下進行。

記憶提示
親密伴侶暴力：隔離、詢問、評估安全。

## 臨床情境

臨床實務指引
親密伴侶暴力照護包括私下篩檢、認可、立即安全評估、資源提供及必要時的強制通報。

注意事項
切勿在個案面前與疑似施暴者對質。

## 重要概念

- **親密伴侶暴力** — 現任或前任伴侶造成的身體、性、心理或控制傷害。
- **安全評估** — 對立即危險及保護選項的評估。
- **創傷知情照護** — 強調安全、選擇、合作、信任與賦權的照護方式。

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